Publications

Clinical Associate Professor, Neurosurgery

Publications

  • Utilization Trends, Cost, and Payments for Adult Spinal Deformity Surgery in Commercial and Medicare-Insured Populations. Neurosurgery Wadhwa, H., Leung, C., Sklar, M., Ames, C. P., Veeravagu, A., Desai, A., Ratliff, J., Zygourakis, C. C. 2022

    Abstract

    BACKGROUND: Previous studies have characterized utilization rates and cost of adult spinal deformity (ASD) surgery, but the differences between these factors in commercially insured and Medicare populations are not well studied.OBJECTIVE: To identify predictors of increased payments for ASD surgery in commercially insured and Medicare populations.METHODS: We identified adult patients who underwent fusion for ASD, 2007 to 2015, in 20% Medicare inpatient file (n = 21614) and MarketScan commercial insurance database (n = 38789). Patient age, sex, race, insurance type, geographical region, Charlson Comorbidity Index, and length of stay were collected. Outcomes included predictors of increased payments, surgical utilization rates, total cost (calculated using Medicare charges and hospital-specific charge-to-cost ratios), and total Medicare and commercial payments for ASD.RESULTS: Rates of fusion increased from 9.0 to 8.4 per 10000 in 2007 to 20.7 and 18.2 per 10000 in 2015 in commercial and Medicare populations, respectively. The Medicare median total charges increased from

  • Augmented reality neuronavigation for en bloc resection of spinal column lesions. World neurosurgery Tigchelaar, S. S., Medress, Z. A., Quon, J., Dang, P., Barbery, D., Bobrow, A., Kin, C., Louis, R., Desai, A. 2022

    Abstract

    Primary tumors involving the spine are relatively rare but represent surgically challenging procedures with high patient morbidity. En bloc resection of these tumors necessitates large exposures, wide tumor margins, and poses risks to functionally relevant anatomical structures. Augmented reality Neuronavigation (ARNV) represents a paradigm shift in neuronavigation, allowing on-demand visualization of 3-Dimensional navigation data in real-time directly in line with the operative field. Here, we describe the first application of ARNV to perform distal sacrococcygectomies for the en bloc removal of sacral and retrorectal lesions involving the coccyx in two patients, as well as a thoracic 9-11 laminectomy with costotransversectomy for en bloc removal of a schwannoma in a third patient. In our experience, ARNV allowed our teams to minimize the length of the incision, reduce the extent of bony resection, and enhanced visualization of critical adjacent anatomy. All tumors were resected en bloc, and the patients recovered well postoperatively, with no known complications. Pathologic analysis confirmed the en bloc removal of these lesions with negative margins. We conclude that AR is an effective strategy for the precise, en bloc removal of spinal lesions including both sacrococcygeal tumors involving the retrorectal space and thoracic schwannomas.

    View details for DOI 10.1016/j.wneu.2022.08.143

    View details for PubMedID 36096393

  • Health Care Resource Utilization in Management of Opioid-Naive Patients With Newly Diagnosed Neck Pain. JAMA network open Jin, M. C., Jensen, M., Zhou, Z., Rodrigues, A., Ren, A., Barros Guinle, M. I., Veeravagu, A., Zygourakis, C. C., Desai, A. M., Ratliff, J. K. 2022; 5 (7): e2222062

    Abstract

    Importance: Research has uncovered heterogeneity and inefficiencies in the management of idiopathic low back pain, but few studies have examined longitudinal care patterns following newly diagnosed neck pain.Objective: To understand health care utilization in patients with new-onset idiopathic neck pain.Design, Setting, and Participants: This cross-sectional study used nationally sourced longitudinal data from the IBM Watson Health MarketScan claims database (2007-2016). Participants included adult patients with newly diagnosed neck pain, no recent opioid use, and at least 1 year of continuous postdiagnosis follow-up. Exclusion criteria included prior or concomitant diagnosis of traumatic cervical disc dislocation, vertebral fractures, myelopathy, and/or cancer. Only patients with at least 1 year of prediagnosis lookback were included. Data analysis was performed from January 2021 to January 2022.Main Outcomes and Measures: The primary outcome of interest was 1-year postdiagnosis health care expenditures, including costs, opioid use, and health care service utilization. Early services were those received within 30 days of diagnosis. Multivariable regression models and regression-adjusted statistics were used.Results: In total, 679 030 patients (310 665 men [45.6%]) met the inclusion criteria, of whom 7858 (1.2%) underwent surgery within 1 year of diagnosis. The mean (SD) age was 44.62 (14.87) years among nonsurgical patients and 49.69 (9.53) years among surgical patients. Adjusting for demographics and comorbidities, 1-year regression-adjusted health care costs were

  • Prediction of Discharge Status and Readmissions after Resection of Intradural Spinal Tumors. Neurospine Jin, M. C., Ho, A. L., Feng, A. Y., Medress, Z. A., Pendharkar, A. V., Rezaii, P., Ratliff, J. K., Desai, A. M. 2022; 19 (1): 133-145

    Abstract

    OBJECTIVE: Intradural spinal tumors are uncommon and while associations between clinical characteristics and surgical outcomes have been explored, there remains a paucity of literature unifying diverse predictors into an integrated risk model. To predict postresection outcomes for patients with spinal tumors.METHODS: IBM MarketScan Claims Database was queried for adult patients receiving surgery for intradural tumors between 2007 and 2016. Primary outcomes-of-interest were nonhome discharge and 90-day postdischarge readmissions. Secondary outcomes included hospitalization duration and postoperative complications. Risk modeling was developed using a regularized logistic regression framework (LASSO, least absolute shrinkage and selection operator) and validated in a withheld subset.RESULTS: A total of 5,060 adult patients were included. Most surgeries utilized a posterior approach (n = 5,023, 99.3%) and tumors were most commonly found in the thoracic region (n = 1,941, 38.4%), followed by the lumbar (n = 1,781, 35.2%) and cervical (n = 1,294, 25.6%) regions. Compared to models using only tumor-specific or patient-specific features, our integrated models demonstrated better discrimination (area under the curve [AUC] [nonhome discharge] = 0.786; AUC [90-day readmissions] = 0.693) and accuracy (Brier score [nonhome discharge] = 0.155; Brier score [90-day readmissions] = 0.093). Compared to those predicted to be lowest risk, patients predicted to be highest-risk for nonhome discharge required continued care 16.3 times more frequently (64.5% vs. 3.9%). Similarly, patients predicted to be at highest risk for postdischarge readmissions were readmitted 7.3 times as often as those predicted to be at lowest risk (32.6% vs. 4.4%).CONCLUSION: Using a diverse set of clinical characteristics spanning tumor-, patient-, and hospitalization-derived data, we developed and validated risk models integrating diverse clinical data for predicting nonhome discharge and postdischarge readmissions.

    View details for DOI 10.14245/ns.2143244.622

    View details for PubMedID 35378587

  • Surgical Outcomes of Human Immunodeficiency Virus-positive Patients Undergoing Lumbar Degenerative Surgery. Clinical spine surgery Varshneya, K., Wadhwa, H., Ho, A. L., Medress, Z. A., Stienen, M. N., Desai, A., Ratliff, J. K., Veeravagu, A. 2021

    Abstract

    STUDY DESIGN: This was a retrospective cohort studying using a national administrative database.OBJECTIVE: The objective of this study was to determine the postoperative complications and quality outcomes of the human immunodeficiency virus (HIV)-positive patients undergoing surgical management for lumbar degenerative disease (LDD).METHODS: This study identified patients with who underwent surgery for LDD between 2007 and 2016. Patients were stratified based on whether they were HIV positive at the time of surgery. Multivariate regression was utilized to reduce the confounding of baseline covariates. Patients who underwent 3 or more levels of surgical correction were under the age of 18 years, or those with any prior history of trauma or tumor were excluded from this study. Baseline comorbidities, postoperative complication rates, and reoperation rates were determined.RESULTS: A total of 120,167 patients underwent primary lumbar degenerative surgery, of which 309 (0.26%) were HIV positive. In multivariate regression analysis, the HIV-positive cohort was more likely to be readmitted at 30 days [odds ratio (OR)=1.9, 95% confidence interval (CI): 1.2-2.8], 60 days (OR=1.7, 95% CI: 1.2-2.5), and 90 days (OR=1.5, 95% CI: 1.0-2.2). The HIV-positive cohort was also more likely to experience any postoperative complication (OR=1.7, 95% CI: 1.2-2.3). Of the major drivers identified, HIV-positive patients had significantly greater odds of cerebrovascular disease and postoperative neurological complications (OR=3.8, 95% CI: 1.8-6.9) and acute kidney injury (OR=3.4, 95% CI: 1.3-7.1). Costs of index hospitalization were not significantly different between the 2 cohorts (

  • External validation of a predictive model of adverse events following spine surgery. The spine journal : official journal of the North American Spine Society Fatemi, P., Zhang, Y., Han, S. S., Purington, N., Zygourakis, C. C., Veeravagu, A., Desai, A., Park, J., Shuer, L. M., Ratliff, J. K. 2021

    Abstract

    BACKGROUND CONTEXT: We lack models that reliably predict 30-day postoperative adverse events (AEs) following spine surgery.PURPOSE: We externally validated a previously developed predictive model for common 30-day adverse events (AEs) after spine surgery.STUDY DESIGN/SETTING: This prospective cohort study utilizes inpatient and outpatient data from a tertiary academic medical center.PATIENT SAMPLE: We assessed a prospective cohort of all 276 adult patients undergoing spine surgery in the Department of Neurosurgery at a tertiary academic institution between April 1, 2018 and October 31, 2018. No exclusion criteria were applied.OUTCOME MEASURES: Incidence of observed AEs was compared with predicted incidence of AEs. Fifteen assessed AEs included: pulmonary complications, congestive heart failure, neurological complications, pneumonia, cardiac dysrhythmia, renal failure, myocardial infarction, wound infection, pulmonary embolus, deep venous thrombosis, wound hematoma, other wound complication, urinary tract infection, delirium, and other infection.METHODS: Our group previously developed the Risk Assessment Tool for Adverse Events after Spine Surgery (RAT-Spine), a predictive model of AEs within 30 days following spine surgery using a cohort of approximately one million patients from combined Medicare and MarketScan databases. We applied RAT-Spine to the single academic institution prospective cohort by entering each patient's preoperative medical and demographic characteristics and surgical type. The model generated a patient-specific overall risk score ranging from 0 to 1 representing the probability of occurrence of any AE. The predicted risks are presented as absolute percent risk and divided into low (<17%), medium (17-28%), and high (>28%).RESULTS: Among the 276 patients followed prospectively, 76 experienced at least one 30-day postoperative AE. Slightly more than half of the cohort were women (53.3%). The median age was slightly lower in the non-AE cohort (63 vs 66.5 years old). Patients with Medicaid comprised 2.5% of the non-AE cohort and 6.6% of the AE cohort. Spinal fusion was performed in 59.1% of cases, which was comparable across cohorts. There was good agreement between the predicted AE and observed AE rates, Area Under the Curve (AUC) 0.64 (95% CI 0.56-0.710). The incidence of observed AEs in the prospective cohort was 17.8% among the low-risk group, 23.0% in the medium-risk group, and 38.4% in the high risk group (p = 0.003).CONCLUSIONS: We externally validated a model for postoperative AEs following spine surgery (RAT-Spine). The results are presented as low-, moderate-, and high-risk designations.

    View details for DOI 10.1016/j.spinee.2021.06.006

    View details for PubMedID 34116215

  • Metastatic Paraganglioma of the Spine With SDHB Mutation: Case Report and Review of the Literature. International journal of spine surgery Jabarkheel, R., Pendharkar, A. V., Lavezo, J. L., Annes, J., Desai, K., Vogel, H., Desai, A. M. 2021; 14 (s4): S37-S45

    Abstract

    Paragangliomas (PGLs) are rare neuroendocrine tumors that can arise from any autonomic ganglion of the body. Most PGLs do not metastasize. Here, we present a rare case of metastatic PGL of the spine in a patient with a germline pathogenic succinate dehydrogenase subunit B (SDHB) mutation.In addition to a case report we provide a literature review of metastatic spinal PGL to highlight the importance of genetic testing and long-term surveillance of these patients.A 45-year-old woman with history of spinal nerve root PGL, 17 years prior, presented with back pain of several months' duration. Imaging revealed multilevel lytic lesions throughout the cervical, thoracic, and lumbar spine as well as involvement of the right mandibular condyle and clavicle. Percutaneous biopsy of the L1 spinal lesion confirmed metastatic PGL and the patient underwent posterior tumor resection and instrumented fusion of T7-T11. Postoperatively the patient was found to have a pathogenic SDHB deletion.Patients with SDHx mutation, particularly SDHB, have increased risk of developing metastatic PGLs. Consequently, these individuals require long-term surveillance given the risk for developing new tumors or disease recurrence, even years to decades after primary tumor resection. Surgical management of spinal metastatic PGL involves correcting spinal instability, minimizing tumor burden, and alleviating epidural cord compression. In patients with metastatic PGL of the spine, genetic testing should be considered.

    View details for DOI 10.14444/7163

    View details for PubMedID 33900943

  • Advanced Age Does Not Impact Outcomes After 1-level or 2-level Lateral Lumbar Interbody Fusion. Clinical spine surgery Wadhwa, H., Oquendo, Y. A., Tigchelaar, S. S., Warren, S. I., Koltsov, J. C., Desai, A., Veeravagu, A., Alamin, T. F., Ratliff, J. K., Hu, S. S., Cheng, I. 2021

    Abstract

    This was a retrospective comparative study.The objective of this study was to assess the effect of increased age on perioperative and postoperative complication rates, reoperation rates, and patient-reported pain and disability scores after lateral lumbar interbody fusion (LLIF).LLIF was developed to minimize soft tissue trauma and reduce the risk of vascular injury; however, there is little evidence regarding the effect of advanced age on outcomes of LLIF.Patients who underwent LLIF from 2009 to 2019 at one institution with a minimum 6-month follow-up were retrospectively reviewed. Patients less than 18 years old with musculoskeletal tumor or trauma were excluded. The primary outcome was the preoperative to postoperative change in the Numeric Pain Rating Scale (NPRS) for back pain. Operative time, estimated blood loss, length of stay, perioperative and 90-day complications, unplanned readmissions, reoperations, and change in Oswestry Disability Index were also evaluated. Relationships with age were assessed both with age as a continuous variable and segmenting by age below 70 versus 70+.In total, 279 patients were included. The median age was 65±13 years and 159 (57%) were female. Age was not related to improvements in back NPRS and Oswestry Disability Index. Operative time, estimated blood loss, length of stay, perioperative and 90-day complications, unplanned readmissions, reoperations, and radiographic fusion rate also were not related to age. After multivariable risk adjustment, increasing age was associated with greater improvements in back NPRS. The decrease in back NPRS was 0.68 (95% confidence interval: 0.14, 1.22; P=0.014) points greater for every 10-year increase in age. Age was not associated with rates of complication, readmission, or reoperation.LLIF is a safe and effective procedure in the elderly population. Advanced age is associated with larger improvements in preoperative back pain. Surgeons should consider the benefits of LLIF and other minimally invasive techniques when evaluating elderly candidates for lumbar fusion.Level III.

    View details for DOI 10.1097/BSD.0000000000001270

    View details for PubMedID 34724454

  • Defining and Describing Treatment Heterogeneity in New-Onset Idiopathic Lower Back and Extremity Pain Through Reconstruction of Longitudinal Care Sequences. The spine journal : official journal of the North American Spine Society Jin, M. C., Azad, T. D., Fatemi, P., Ho, A. L., Vail, D., Zhang, Y., Feng, A. Y., Kim, L. H., Bentley, J. P., Stienen, M. N., Li, G., Desai, A. M., Veeravagu, A., Ratliff, J. K. 2021

    Abstract

    Despite established guidelines, long-term management of surgically-treated low back pain (LBP) and lower extremity pain (LEP) remains heterogeneous. Understanding care heterogeneity could inform future approaches for standardization of practices.To describe treatment heterogeneity in surgically-managed LBP and LEP.Retrospective study of a nationwide commercial database spanning inpatient and outpatient encounters for enrollees of eligible employer-supplied healthcare plans (2007-2016).A population-based sample of opioid-naïve adult patients with newly-diagnosed LBP or LEP were identified. Inclusion required at least 12-months of pre-diagnosis and post-diagnosis continuous follow-up.Included treatments/evaluations include conservative management (chiropractic manipulative therapy, physical therapy, epidural steroid injections), imaging (x-ray, MRI, CT), pharmaceuticals (opioids, benzodiazepines), and spine surgery (decompression, fusion).Primary outcomes-of-interest were 12-month net healthcare expenditures (inpatient and outpatient) and 12-month opioid usage.Analyses include interrogation of care sequence heterogeneity and temporal trends in sequence-initiating services. Comparisons were conducted in the framework of sequence-specific treatment sequences, which reflect the personalized order of healthcare services pursued by each patient. Outlier sequences characterized by high opioid use and costs were identified from frequently observed surgical treatment sequences using Mahalanobis distance.A total of 2,496,908 opioid-naïve adult patients with newly-diagnosed LBP or LEP were included (29,519 surgical). In the matched setting, increased care sequence heterogeneity was observed in surgical patients (0.51 vs 0.12 previously-unused interventions/studies pursued per month). Early opioid and MRI use has decreased between 2008 and 2015 but is matched by increases in early benzodiazepine and x-ray use. Outlier sequences, characterized by increased opioid use and costs, were found in 5.8% of surgical patients. Use of imaging prior to conservative management was common in patients pursuing outlier sequences compared to non-outlier sequences (96.5% vs 63.8%, p<0.001). Non-outlier sequences were more frequently characterized by early conservative interventions (31.9% vs 7.4%, p<0.001).Surgically-managed LBP and LEP care sequences demonstrate high heterogeneity despite established practice guidelines. Outlier sequences associated with high opioid usage and costs can be identified and are characterized by increased early imaging and decreased early conservative management. Elements that may portend suboptimal longitudinal management could provide opportunities for standardization of patient care.

    View details for DOI 10.1016/j.spinee.2021.05.019

    View details for PubMedID 34033933

  • Obesity in Patients Undergoing Lumbar Degenerative Surgery-A Retrospective Cohort Study of Postoperative Outcomes. Spine Varshneya, K., Wadhwa, H., Stienen, M. N., Ho, A. L., Medress, Z. A., Aikin, J., Li, G., Desai, A., Ratliff, J. K., Veeravagu, A. 2021; 46 (17): 1191-1196

    Abstract

    Retrospective cohort studying using a national, administrative database.The aim of this study was to determine the postoperative complications and quality outcomes of patients with and without obesity undergoing surgical management for lumbar degenerative disease (LDD).Obesity is a global epidemic that negatively impacts health outcomes. Characterizing the effect of obesity on LDD surgery is important given the growing elderly obese population.This study identified patients with who underwent surgery for LDD between 2007 and 2016. Patients were stratified based on whether the patient had a concurrent diagnosis of obesity at time of surgery. Propensity score matching (PSM) was then utilized to mitigate intergroup differences between patients with and without obesity. Patients who underwent three or more levels surgical correction, were under the age of 18 years, or those with any previous history of trauma or tumor were excluded from this study. Baseline comorbidities, postoperative complication rates, and reoperation rates were determined.A total of 67,215 patients underwent primary lumbar degenerative surgery, of which 22,405 (33%) were obese. After propensity score matching, baseline covariates of the two cohorts were similar. The complication rate was 8.3% in the nonobese cohort and 10.4% in the obese cohort (P < 0.0001). Patients with obesity also had longer lengths of stay (2.7 days vs. 2.4 days, P < 0.05), and higher rates of reoperation and readmission at all time-points through the study follow-up period to their nonobese counterparts (P < 0.05). Including payments after discharge, lumbar degenerative surgery in patients with obesity was associated with higher payments throughout the 2-year follow-up period (

  • Single vs Multistage Surgical Management of Single and Two-Level Lumbar Degenerative Disease. World neurosurgery Varshneya, K., Wadhwa, H., Stienen, M. N., Ho, A. L., Medress, Z. A., Herrick, D. B., Desai, A., Ratliff, J. K., Veeravagu, A. 2021

    Abstract

    Retrospective cohort studying using a national, administrative database.To determine the postoperative complications and quality outcomes of single and multi-stage surgical management for lumbar degenerative disease (LDD).This study identified patients with who underwent surgery for LDD between 2007 - 2016. Patients were stratified based on whether their surgeon choose to correct their LDD in a single or multistage manner, and these cohorts were mutually exclusive. Propensity score matching (PSM) was then utilized to mitigate intergroup differences between single and multi-stage patients. Patients who underwent three or more levels surgical correction, were under the age of 18 years, or those with any prior history of trauma or tumor were excluded from this study. Baseline comorbidities, postoperative complication rates, and reoperation rates were determined.A total of 47,190 patients underwent primary surgery for LDD, of which 9,438 (20%) underwent multi-stage surgery. After propensity score matching, baseline covariates of the two cohorts were similar. The complication rate was 6.1% in the single stage cohort and 11.0% in the multistage cohort. Rates of post-hemorrhagic anemia, infection, wound complication, DVT, and hematoma were all higher in the multistage cohort. Lengths of stay, revision, and readmission rates were also significantly higher in the multi-stage cohort. Through 2-years of follow up, multi-stage surgery was associated with higher payments throughout the 2-year follow-up period (

  • Predictive Modeling of Long-Term Opioid and Benzodiazepine Use after Intradural Tumor Resection. The spine journal : official journal of the North American Spine Society Jin, M. C., Ho, A. L., Feng, A. Y., Zhang, Y., Staartjes, V. E., Stienen, M. N., Han, S. S., Veeravagu, A., Ratliff, J. K., Desai, A. M. 2020

    Abstract

    INTRODUCTION: Despite increased awareness of the ongoing opioid epidemic, opioid and benzodiazepine use remain high after spine surgery. In particular, long-term co-prescription of opioids and benzodiazepines have been linked to high risk of overdose-associated death. Tumor patients represent a unique subset of spine surgery patients and few studies have attempted to develop predictive models to anticipate long-term opioid and benzodiazepine use after spinal tumor resection.METHODS: The IBM Watson Health MarketScan Database and Medicare Supplement were assessed to identify admissions for intradural tumor resection between 2007 and 2015. Adult patients were required to have at least 6-months of continuous pre-admission baseline data and 12-months of continuous post-discharge follow-up. Primary outcomes were long-term opioid and benzodiazepine use, defined as at least 6 prescriptions within 12 months. Secondary outcomes were durations of opioid and benzodiazepine prescribing. Logistic regression models, with and without regularization, were trained on an 80% training sample and validated on the withheld 20%.RESULTS: A total of 1,942 patients were identified. The majority of tumors were extramedullary (74.8%) and benign (62.5%). A minority of patients received arthrodesis (9.2%) and most patients were discharged to home (79.1%). Factors associated with post-discharge opioid use duration include tumor malignancy (vs benign, B=19.8 prescribed-days/year, 95% CI 1.1 to 38.5) and intramedullary compartment (vs extramedullary, B=18.1 prescribed-days/year, 95% CI 3.3 to 32.9). Pre- and peri-operative use of prescribed NSAIDs and gabapentin/pregabalin were associated with shorter and longer duration opioid use, respectively. History of opioid and history of benzodiazepine use were both associated with increased post-discharge opioid and benzodiazepine use. Intramedullary location was associated with longer duration post-discharge benzodiazepine use (B=10.3 prescribed-days/year, 95% CI 1.5 to 19.1). Among assessed models, elastic net regularization demonstrated best predictive performance in the withheld validation cohort when assessing both long-term opioid use (AUC=0.748) and long-term benzodiazepine use (AUC=0.704). Applying our model to the validation set, patients scored as low-risk demonstrated a 4.8% and 2.4% risk of long-term opioid and benzodiazepine use, respectively, compared to 35.2% and 11.1% of high-risk patients.CONCLUSIONS: We developed and validated a parsimonious, predictive model to anticipate long-term opioid and benzodiazepine use early after intradural tumor resection, providing physicians opportunities to consider alternative pain management strategies.

    View details for DOI 10.1016/j.spinee.2020.10.010

    View details for PubMedID 33065272

  • The Effect of Socioeconomic Status on Age at Diagnosis and Overall Survival in Patients with Intracranial Meningioma. The International journal of neuroscience Brewster, R., Deb, S., Pendharkar, A. V., Ratliff, J., Li, G., Desai, A. 2020: 1–12

    Abstract

    Background: Intracranial meningiomas are the most common primary tumors of the central nervous system. How socioeconomic status (SES) impacts treatment access and outcomes for brain tumor subtypes is an emerging area of research. Few studies have examined the relationship between SES and meningioma survival and management with reference to relevant clinical factors, including age at diagnosis. We studied the independent effects of SES on receiving surgery and survival probability in patients with intracranial meningiomaMethods: 54,282 patients diagnosed with intracranial meningioma between 2003-2012 from the Surveillance, Epidemiology, and End Results (SEER) Program at the National Cancer Institute database were included. Patient SES was divided into tertiles. Patient age groups included "older" (>65, the median patient age) and "younger". Multivariable linear regression and Cox proportional hazards model were used with SAS v9.4. Results were adjusted for race, sex, and tumor grade. Kaplan Meier survival curves were constructed according to SES tertiles and age groups.Results: Meningioma prevalence increased with higher SES tertile. Higher SES tertile was also associated with younger age at diagnosis (OR= 0.890, p <0.05), an increased likelihood of undergoing gross total resection (GTR) (OR =1.112, p<0.05), and a trend towards greater 5-year survival probability (HR =1.773, p=0.0531). Survival probability correlated with younger age at diagnosis (HR =2.597, p<0.001), but not with GTR receipt.Conclusion: The findings from this national longitudinal study on patients with meningioma suggest that SES affects age at diagnosis and treatment access for intracranial meningiomas patients. Further studies are required to understand and address the mechanisms underlying these disparities.

    View details for DOI 10.1080/00207454.2020.1818742

    View details for PubMedID 32878534

  • A Comparative Analysis of Patients Undergoing Fusion for Adult Cervical Deformity by Approach Type. Global spine journal Varshneya, K., Medress, Z. A., Stienen, M. N., Nathan, J., Ho, A., Pendharkar, A. V., Loo, S., Aikin, J., Li, G., Desai, A., Ratliff, J. K., Veeravagu, A. 2020: 2192568220915717

    Abstract

    Retrospective cohort study.To provide insight into postoperative complications, short-term quality outcomes, and costs of the surgical approaches of adult cervical deformity (ACD).A national database was queried from 2007 to 2016 to identify patients who underwent cervical fusion for ACD. Patients were stratified by approach type-anterior, posterior, or circumferential. Patients undergoing anterior and posterior approach surgeries were additionally compared using propensity score matching.A total of 6575 patients underwent multilevel cervical fusion for ACD correction. Circumferential fusion had the highest postoperative complication rate (46.9% vs posterior: 36.7% vs anterior: 18.5%, P < .0001). Anterior fusion patients more commonly required reoperation compared with posterior fusion patients (P < .0001), and 90-day readmission rate was highest for patients undergoing circumferential fusion (P < .0001). After propensity score matching, the complication rate remained higher in the posterior, as compared to the anterior fusion group (P < .0001). Readmission rate also remained higher in the posterior fusion group; however, anterior fusion patients were more likely to require reoperation. At index hospitalization, posterior fusion led to 1.5× higher costs, and total payments at 90 days were 1.6× higher than their anterior fusion counterparts.Patients who undergo posterior fusion for ACD have higher complication rates, readmission rates, and higher cost burden than patients who undergo anterior fusion; however, posterior correction of ACD is associated with a lower rate of reoperation.

    View details for DOI 10.1177/2192568220915717

    View details for PubMedID 32875897

  • A Comparative Analysis of Patients Undergoing Fusion for Adult Cervical Deformity by Approach Type GLOBAL SPINE JOURNAL Varshneya, K., Medress, Z. A., Stienen, M. N., Nathan, J., Ho, A., Pendharkar, A. V., Loo, S., Aikin, J., Li, G., Desai, A., Ratliff, J. K., Veeravagu, A. 2020
  • Objective activity tracking in spine surgery: a prospective feasibility study with a low-cost consumer grade wearable accelerometer. Scientific reports Stienen, M. N., Rezaii, P. G., Ho, A. L., Veeravagu, A., Zygourakis, C. C., Tomkins-Lane, C., Park, J., Ratliff, J. K., Desai, A. M. 2020; 10 (1): 4939

    Abstract

    Patient-reported outcome measures (PROMs) are commonly used to estimate disability of patients with spinal degenerative disease. Emerging technological advances present an opportunity to provide objective measurements of activity. In a prospective, observational study we utilized a low-cost consumer grade wearable accelerometer (LCA) to determine patient activity (steps per day) preoperatively (baseline) and up to one year (Y1) after cervical and lumbar spine surgery. We studied 30 patients (46.7% male; mean age 57 years; 70% Caucasian) with a baseline activity level of 5624 steps per day. The activity level decreased by 71% in the 1st postoperative week (p<0.001) and remained 37% lower in the 2nd (p<0.001) and 23% lower in the 4th week (p=0.015). At no time point until Y1 did patients increase their activity level, compared to baseline. Activity was greater in patients with cervical, as compared to patients with lumbar spine disease. Age, sex, ethnic group, anesthesia risk score and fusion were variables associated with activity. There was no correlation between activity and PROMs, but a strong correlation with depression. Determining activity using LCAs provides real-time and longitudinal information about patient mobility and return of function. Recovery took place over the first eight postoperative weeks, with subtle improvement afterwards.

    View details for DOI 10.1038/s41598-020-61893-4

    View details for PubMedID 32188895

  • Postoperative Complication Burden, Revision Risk, and Health Care Use in Obese Patients Undergoing Primary Adult Thoracolumbar Deformity Surgery GLOBAL SPINE JOURNAL Varshneya, K., Pangal, D. J., Stienen, M. N., Ho, A. L., Fatemi, P., Medress, Z. A., Herrick, D. B., Desai, A., Ratliff, J. K., Veeravagu, A. 2020
  • Postoperative Complication Burden, Revision Risk, and Health Care Use in Obese Patients Undergoing Primary Adult Thoracolumbar Deformity Surgery. Global spine journal Varshneya, K., Pangal, D. J., Stienen, M. N., Ho, A. L., Fatemi, P., Medress, Z. A., Herrick, D. B., Desai, A., Ratliff, J. K., Veeravagu, A. 2020: 2192568220904341

    Abstract

    This is a retrospective cohort study using a nationally representative administrative database.To identify the impact of obesity on postoperative outcomes in patients undergoing thoracolumbar adult spinal deformity (ASD) surgery.The obesity rate in the United States remains staggering, with approximately one-third of all Americans being overweight or obese. However, the impact of elevated body mass index on spine surgery outcomes remains unclear.We queried the MarketScan database to identify patients who were diagnosed with a spinal deformity and underwent ASD surgery from 2007 to 2016. Patients were then stratified by whether or not they were diagnosed as obese at index surgical admission. Propensity score matching (PSM) was then utilized to mitigate intergroup differences between obese and nonobese patients. Patients <18 years and those with any prior history of trauma or tumor were excluded from this study. Baseline demographics and comorbidities, postoperative complication rates, and short- and long-term reoperation rates were determined.A total of 7423 patients met the inclusion criteria of this study, of whom 597 (8.0%) were obese. Initially, patients with obesity had a higher 90-day postoperative complication rate than nonobese patients (46.1% vs 40.8%, P < .05); however, this difference did not remain after PSM. Revision surgery rates after 2 years were similar across the 2 groups following primary surgery (obese, 21.4%, vs nonobese, 22.0%; P = .7588). Health care use occurred at a higher rate among obese patients through 2 years of long-term follow-up (obese,

  • Functional Mapping for Glioma Surgery: A Propensity-matched Analysis of Outcomes and Cost. World neurosurgery Pendharkar, A. V., Rezaii, P. G., Ho, A. L., Sussman, E. S., Li, G. n., Desai, A. M. 2020

    Abstract

    To compare clinical outcomes and payments between glioma resections with and without functional mapping.The Thomas Reuters MarketScan national longitudinal database was used to identify patients undergoing resection of supratentorial primary malignant glioma with or without functional mapping between 2007-2016. Patients were stratified into mapped and unmapped (conventional) groups, and subsequently propensity-matched based on demographics, clinical comorbidities, and surgical characteristics (i.e., use of stereotactic navigation, microscope, intratumoral chemotherapy). Outcomes and charges were compared between matched groups using bivariate analyses.A total of 14,037 patients were identified, of which 796 (6.0%) received functional mapping. Propensity-matching (1:1) resulted in 796 mapped patients and 796 propensity-matched controls. Thirty-day postoperative rates of new-onset seizures, cerebral edema, hemorrhage, and neurological deficits were significantly lower for the functional mapping group (all p < 0.05). Functional mapping was also associated with shorter hospital length of stay (p = .0144), lower 30-day rates of emergency department visits (p = .0001) and fewer reoperations (p = .0068). Total costs of initial admission were not significantly different between groups.Intraoperative functional mapping during glioma resection was associated with decreased complications, reoperations, emergency department visits, and shorter lengths of stay. Furthermore, total charges of mapped resections were not significantly different from those of conventional resections. These findings support the utility of functional mapping for resection of supratentorial primary malignant gliomas.

    View details for DOI 10.1016/j.wneu.2020.01.197

    View details for PubMedID 32028000

  • A Predictive-Modeling Based Screening Tool for Prolonged Opioid Use after Surgical Management of Low Back and Lower Extremity Pain. The spine journal : official journal of the North American Spine Society Zhang, Y. n., Fatemi, P. n., Medress, Z. n., Azad, T. D., Veeravagu, A. n., Desai, A. n., Ratliff, J. K. 2020

    Abstract

    Outpatient postoperative pain management in spine patients, specifically involving the use of opioids, demonstrates significant variability.Using preoperative risk factors and 30-day postoperative opioid prescribing patterns, we developed models for predicting long-term opioid use in patients after elective spine surgery.This retrospective cohort study utilizes inpatient, outpatient, and pharmaceutical data from MarketScan databases (Truven Health).In all, 19,317 patients who were newly diagnosed with low back or lower extremity pain (LBP or LEP) between 2008 and 2015 and underwent thoracic or lumbar surgery within one year after diagnosis were enrolled. Some patients initiated opioids after diagnosis but all patients were opioid-naïve prior to the diagnosis.Long-term opioid use was defined as filling ≥180 days of opioids within one year after surgery.Using demographic variables, medical and psychiatric comorbidities, preoperative opioid use, and 30-day postoperative opioid use, we generated seven models on 80% of the dataset and tested the models on the remaining 20%. We used three regression-based models (full logistic regression, stepwise logistic regression, least absolute shrinkage and selection operator [LASSO]), support vector machine, two tree-based models (random forest, stochastic gradient boosting), and time-varying convolutional neural network. Area under the curve (AUC), Brier index, sensitivity, and calibration curves were used to assess the discrimination and calibration of the models.We identified 903 (4.6%) of patients who met criteria for long-term opioid use. The regression-based models demonstrated the highest AUC, ranging from 0.835 to 0.847, and relatively high sensitivities, predicting between 74.9-76.5% of the long-term opioid use patients in the test dataset. The three strongest positive predictors of long-term opioid use were high preoperative opioid use (OR 2.70; 95% CI 2.27-3.22), number of days with active opioid prescription between postoperative days 15-30 (OR 1.10; 95% CI 1.07-1.12), and number of dosage increases between postoperative day 15-30 (OR 1.71, 95% CI 1.41-2.08). The strongest negative predictors were number of dosage decreases in the 30-day postoperative period.We evaluated several predictive models for postoperative long-term opioid use in a large cohort of patients with LBP or LEP who underwent surgery. A regression-based model with high sensitivity and AUC is provided online to screen patients for high risk of long-term opioid use based on preoperative risk factors and opioid prescription patterns in the first 30 days after surgery. It is hoped that this work will improve identification of patients at high risk of prolonged opioid use and enable early intervention and counseling.

    View details for DOI 10.1016/j.spinee.2020.05.098

    View details for PubMedID 32445803

  • Conventional Versus Stereotactic Image Guided Pedicle Screw Placement During Spinal Deformity Correction: A Retrospective Propensity Score-Matched Study of a National Longitudinal Database. The International journal of neuroscience Rezaii, P. G., Pendharkar, A. V., Ho, A. L., Sussman, E. S., Veeravagu, A. n., Ratliff, J. K., Desai, A. M. 2020: 1–13

    Abstract

    Purpose/aim: To compare complications, readmissions, revisions, and payments between navigated and conventional pedicle screw fixation for treatment of spine deformity.Methods: The Thomson Reuters MarketScan national longitudinal database was used to identify patients undergoing osteotomy, posterior instrumentation, and fusion for treatment of spinal deformity with or without image-guided navigation between 2007-2016. Conventional and navigated groups were propensity-matched (1:1) to normalize differences between demographics, comorbidities, and surgical characteristics. Clinical outcomes and charges were compared between matched groups using bivariate analyses.Results: A total of 4,604 patients were identified as having undergone deformity correction, of which 286 (6.2%) were navigated. Propensity-matching resulted in a total of 572 well-matched patients for subsequent analyses, of which half were navigated. Rate of mechanical instrumentation-related complications was found to be significantly lower for navigated procedures (p = 0.0371). Navigation was also associated with lower rates of 90-day unplanned readmissions (p = 0.0295), as well as 30- and 90-day postoperative revisions (30-day: p = 0.0304, 90-day: p = 0.0059). Hospital, physician, and total payments favored the conventional group for initial admission (p = 0.0481, 0.0001, 0.0019, respectively); however, when taking into account costs of readmissions, hospital payments became insignificantly different between the two groups.Conclusions: Procedures involving image-guided navigation resulted in decreased instrumentation-related complications, unplanned readmissions, and postoperative revisions, highlighting its potential utility for the treatment of spine deformity. Future advances in navigation technologies and methodologies can continue to improve clinical outcomes, decrease costs, and facilitate widespread adoption of navigation for deformity correction.

    View details for DOI 10.1080/00207454.2020.1763343

    View details for PubMedID 32364414

  • Association between Physician Industry Payments and Cost of Anterior Cervical Discectomy and Fusion in Medicare Beneficiaries. World neurosurgery Liu, C. n., Ahmed, K. n., Chen, C. L., Dudley, R. A., Gonzales, R. n., Orrico, K. n., Yerneni, K. n., Stienen, M. N., Veeravagu, A. n., Desai, A. n., Park, J. n., Ratliff, J. K., Zygourakis, C. C. 2020

    Abstract

    Neurosurgical spine specialists receive considerable amounts of industry support which may impact the cost of care. The aim of this study was to evaluate the association between industry payments received by spine surgeons and the total hospital and operating room (OR) costs of an anterior cervical discectomy and fusion (ACDF) procedure among Medicare beneficiaries.All ACDF cases were identified among the Medicare Carrier Files, from January 1, 2013, to December 31, 2014, and matched to the Medicare Inpatient Baseline File. The total hospital and OR charges were obtained for these cases. Charges were converted to cost using year-specific cost-to-charge ratios. Surgeons were identified among Open Payments database, which is used to quantify industry support. Analyses was performed to examine the association between industry payments received and ACDF costs.Matching resulting in the inclusion of 2,209 ACDF claims from 2013-2014. In 2013 and 2014, the mean total cost for an ACDF was

  • Adverse Events and Bundled Costs after Cranial Neurosurgical Procedures: Validation of the LACE Index Across 40,431 Admissions and Development of the LACE-Cranial Index. World neurosurgery Jin, M. C., Wu, A. n., Medress, Z. A., Parker, J. J., Desai, A. n., Veeravagu, A. n., Grant, G. A., Li, G. n., Ratliff, J. K. 2020

    Abstract

    Anticipating post-discharge complications following neurosurgery remains difficult. The LACE index, based on four hospitalization descriptors, stratifies patients by risk of 30-day post-discharge adverse events but has not been validated in a procedure-specific manner in neurosurgery. Our study sought to explore the utility of the LACE index in cranial neurosurgery population and to develop an enhanced model, LACE-Cranial.The Optum Clinformatics Database was used to identify cranial neurosurgery admissions (2004-2017). Procedures were grouped as trauma/hematoma/ICP, open vascular, functional/pain, skull base, tumor, or endovascular. Adverse events were defined as post-discharge death/readmission. LACE-Cranial was developed using a logistic regression framework incorporating an expanded feature set in addition to the original LACE components.A total of 40,431 admissions were included. Predictions of 30-day readmissions was best for skull-base (AUC=0.636) and tumor (AUC=0.63) admissions but was generally poor. Predictive ability of 30-day mortality was best for functional/pain admissions (AUC=0.957) and poorest for trauma/hematoma/ICP admissions (AUC=0.613). Across procedure types except for functional/pain, a high-risk LACE score was associated with higher post-discharge bundled payment costs. Incorporating features identified to contribute independent predictive value, the LACE-Cranial model achieved procedure-specific 30-day mortality AUCs ranging from 0.904 to 0.98. Prediction of 30-day and 90-day readmissions was also improved, with tumor and skull base cases achieving 90-day readmission AUCs of 0.718 and 0.717, respectively.While the unmodified LACE index demonstrates inconsistent classification performance, the enhanced LACE-Cranial model offers excellent prediction of short-term post-discharge mortality across procedure groups and significantly improved anticipation of short-term post-discharge readmissions.

    View details for DOI 10.1016/j.wneu.2020.10.103

    View details for PubMedID 33127572

  • Opioid Use in Adults with Low Back or Lower Extremity Pain who Undergo Spine Surgical Treatment within One Year of Diagnosis. Spine Fatemi, P. n., Zhang, Y. n., Ho, A. n., Lama, R. n., Jin, M. n., Veeravagu, A. n., Desai, A. n., Ratliff, J. K. 2020

    Abstract

    Retrospective longitudinal cohort.We investigated opioid prescribing patterns amongst adults in the United States diagnosed with low back or lower extremity pain (LBP/LEP) who underwent spine surgery.Opioid-based treatment of LBP/LEP and postsurgical pain have separately been associated with chronic opioid use, but a combined and large-scale cohort study is missing.This study utilizes commercial inpatient, outpatient, and pharmaceutical insurance claims. Between 2008 and 2015, patients without prior prescription opioids with a new diagnosis of LBP/LEP who underwent surgery within one year after diagnosis were enrolled. Opioid prescribing patterns after LBP/LEP diagnosis and after surgery were evaluated. All patients had one-year postoperative follow-up. Low and high frequency (≥6 refills in 12 months) opioid prescription groups were identified.25,506 patients without prior prescription opioids were diagnosed with LBP/LEP and underwent surgery within one year of diagnosis. After LBP/LEP diagnosis, 18,219 (71.4%) were prescribed opioids while 7,287 (28.6%) were not. After surgery, 2,952 (11.6%) were prescribed opioids with high frequency and 22,554 (88.4%) with low frequency. Among patients prescribed opioids prior to surgery, those with high frequency prescriptions were more likely to continue this pattern postoperatively than those with low frequency prescriptions preoperatively (OR:2.15, 95% CI:1.97-2.34). For those prescribed opioids preoperatively, average daily morphine milligram equivalent (MME) decreased after surgery (by 2.62 in decompression alone cohort and 0.25 in arthrodesis cohort, p < 0.001). Postoperative low-frequency patients were more likely than high-frequency patients to discontinue opioids one-year after surgery (OR:3.78, 95% CI:3.59-3.99). Postoperative high-frequency patients incurred higher cost than low-frequency patients. Postoperative high-frequency prescribing varied widely across states (4.3%-20%).A stepwise association exists between opioid use after LEP or LBP diagnosis and frequency and duration of opioid prescriptions after surgery. Simultaneously, the strength of prescriptions as measured by MME decreased following surgery.3.

    View details for DOI 10.1097/BRS.0000000000003663

    View details for PubMedID 32833930

  • Cervical osteochondroma: surgical planning. Spinal cord series and cases Fowler, J. n., Takayanagi, A. n., Siddiqi, I. n., Ghanchi, H. n., Siddiqi, J. n., Veeravagu, A. n., Desai, A. n., Vrionis, F. n., Hariri, O. R. 2020; 6 (1): 44

    Abstract

    Osteochondromas are benign bone tumors which occur as solitary lesions or as part of the syndrome multiple hereditary exostoses. While most osteochondromas occur in the appendicular skeleton, they can also occur in the spine. Most lesions are asymptomatic however some may encroach on the spinal cord or the nerve roots causing neurological symptoms. While most patients with osteochondromas undergo laminectomy without fusion, laminectomy with fusion is indicated in appropriately selected cases of spinal decompression.We present a case of a 32-year-old male with history of multiple hereditary exostoses who presented with symptoms of bilateral upper extremity numbness and complaints of gait imbalance and multiple falls. He reported rapid progression of his symptoms during the 10 days before presentation. Computed tomography of the cervical spine revealed a lobulated bony tumor along the inner margin of the cervical 4 lamina. He underwent cervical 3 and 4 laminectomies, partial cervical 2 and 5 laminectomies and cervical 3-5 mass screw placement. Pathology was consistent with osteochondroma. The patient's symptoms had markedly improved at follow-up.According to our literature review, osteochondromas most commonly occur at cervical 2 and cervical 5. We present a case of an osteochondroma at a less common level, cervical 4. While most osteochondromas are addressed with laminectomy without arthrodesis, the decision of whether arthrodesis is necessary should be considered in all patients with osteochondroma as with any cervical decompression.

    View details for DOI 10.1038/s41394-020-0292-7

    View details for PubMedID 32467563

  • Normative data of a smartphone app-based 6-minute walking test, test-retest reliability, and content validity with patient-reported outcome measures. Journal of neurosurgery. Spine Tosic, L. n., Goldberger, E. n., Maldaner, N. n., Sosnova, M. n., Zeitlberger, A. M., Staartjes, V. E., Gadjradj, P. S., Eversdijk, H. A., Quddusi, A. n., Gandía-González, M. L., Sayadi, J. J., Desai, A. n., Regli, L. n., Gautschi, O. P., Stienen, M. N. 2020: 1–10

    Abstract

    The 6-minute walking test (6WT) is used to determine restrictions in a subject's 6-minute walking distance (6WD) due to lumbar degenerative disc disease. To facilitate simple and convenient patient self-measurement, a free and reliable smartphone app using Global Positioning System coordinates was previously designed. The authors aimed to determine normative values for app-based 6WD measurements.The maximum 6WD was determined three times using app-based measurement in a sample of 330 volunteers without previous spine surgery or current spine-related disability, recruited at 8 centers in 5 countries (mean subject age 44.2 years, range 16-91 years; 48.5% male; mean BMI 24.6 kg/m2, range 16.3-40.2 kg/m2; 67.9% working; 14.2% smokers). Subjects provided basic demographic information, including comorbidities and patient-reported outcome measures (PROMs): visual analog scale (VAS) for both low-back and lower-extremity pain, Core Outcome Measures Index (COMI), Zurich Claudication Questionnaire (ZCQ), and subjective walking distance and duration. The authors determined the test-retest reliability across three measurements (intraclass correlation coefficient [ICC], standard error of measurement [SEM], and mean 6WD [95% CI]) stratified for age and sex, and content validity (linear regression coefficients) between 6WD and PROMs.The ICC for repeated app-based 6WD measurements was 0.89 (95% CI 0.87-0.91, p < 0.001) and the SEM was 34 meters. The overall mean 6WD was 585.9 meters (95% CI 574.7-597.0 meters), with significant differences across age categories (p < 0.001). The 6WD was on average about 32 meters less in females (570.5 vs 602.2 meters, p = 0.005). There were linear correlations between average 6WD and VAS back pain, VAS leg pain, COMI Back and COMI subscores of pain intensity and disability, ZCQ symptom severity, ZCQ physical function, and ZCQ pain and neuroischemic symptoms subscores, as well as with subjective walking distance and duration, indicating that subjects with higher pain, higher disability, and lower subjective walking capacity had significantly lower 6WD (all p < 0.001).This study provides normative data for app-based 6WD measurements in a multicenter sample from 8 institutions and 5 countries. These values can now be used as reference to compare 6WT results and quantify objective functional impairment in patients with degenerative diseases of the spine using z-scores. The authors found a good to excellent test-retest reliability of the 6WT app, a low area of uncertainty, and high content validity of the average 6WD with commonly used PROMs.

    View details for DOI 10.3171/2020.3.SPINE2084

    View details for PubMedID 32470938

  • Digital transformation in spine research and outcome assessment. The spine journal : official journal of the North American Spine Society Maldaner, N. n., Tomkins-Lane, C. n., Desai, A. n., Zygourakis, C. C., Weyerbrock, A. n., Gautschi, O. P., Stienen, M. N. 2020; 20 (2): 310–11

    View details for DOI 10.1016/j.spinee.2019.06.027

    View details for PubMedID 32000961

  • Adult Spinal Deformity Surgery in Patients With Movement Disorders: A Propensity-matched Analysis of Outcomes and Cost. Spine Varshneya, K. n., Azad, T. D., Pendharkar, A. V., Desai, A. n., Cheng, I. n., Karikari, I. n., Ratliff, J. K., Veeravagu, A. n. 2020; 45 (5): E288–E295

    Abstract

    This was a retrospective study using national administrative data from the MarketScan database.To investigate the complication rates, quality outcomes, and costs in a nationwide cohort of patients with movement disorders (MD) who undergo spinal deformity surgery.Patients with MD often present with spinal deformities, but their tolerance for surgical intervention is unknown.The MarketScan administrative claims database was queried to identify adult patients with MD who underwent spinal deformity surgery. A propensity-score match was conducted to create two uniform cohorts and mitigate interpopulation confounders. Perioperative complication rates, 90-day postoperative outcomes, and total costs were compared between patients with MD and controls.A total of 316 patients with MD (1.7%) were identified from the 18,970 undergoing spinal deformity surgery. The complication rate for MD patients was 44.6% and for the controls 35.6% (P = 0.009). The two most common perioperative complications were more likely to occur in MD patients, acute-posthemorrhagic anemia (26.9% vs. 20.8%, P < 0.05) and deficiency anemia (15.5% vs. 8.5%, P < 0.05). At 90 days, MD patients were more likely to be readmitted (17.4% vs. 13.2%, P < 0.05) and have a higher total cost (

  • Improving the Patient-Physician Relationship in the Digital Era - Transformation From Subjective Questionnaires Into Objective Real-Time and Patient-Specific Data Reporting Tools. Neurospine Maldaner, N., Desai, A., Gautschi, O. P., Regli, L., Ratliff, J. K., Park, J., Stienen, M. N. 2019; 16 (4): 712–14

    View details for DOI 10.14245/ns.1938400.200

    View details for PubMedID 31905462

  • Timing of Adjuvant Radiation Therapy and Risk of Wound-Related Complications Among Patients With Spinal Metastatic Disease. Global spine journal Azad, T. D., Varshneya, K., Herrick, D. B., Pendharkar, A. V., Ho, A. L., Stienen, M., Zygourakis, C., Bagshaw, H. P., Veeravagu, A., Ratliff, J. K., Desai, A. 2019: 2192568219889363

    Abstract

    This was an epidemiological study using national administrative data from the MarketScan database.To investigate the impact of early versus delayed adjuvant radiotherapy (RT) on wound healing following surgical resection for spinal metastatic disease.We queried the MarketScan database (2007-2016), identifying patients with a diagnosis of spinal metastasis who also underwent RT within 8 weeks of surgery. Patients were categorized into "Early RT" if they received RT within 4 weeks of surgery and as "Late RT" if they received RT between 4 and 8 weeks after surgery. Descriptive statistics and hypothesis testing were used to compare baseline characteristics and wound complication outcomes.A total of 540 patients met the inclusion criteria: 307 (56.9%) received RT within 4 weeks (Early RT) and 233 (43.1%) received RT within 4 to 8 weeks (Late RT) of surgery. Mean days to RT for the Early RT cohort was 18.5 (SD, 6.9) and 39.7 (SD, 7.6) for the Late RT cohort. In a 90-day surveillance period, n = 9 (2.9%) of Early RT and n = 8 (3.4%) of Late RT patients developed wound complications (P = .574).When comparing patients who received RT early versus delayed following surgery, there were no significant differences in the rates of wound complications. Further prospective studies should aim to identify optimal patient criteria for early postoperative RT for spinal metastases.

    View details for DOI 10.1177/2192568219889363

    View details for PubMedID 32875859

  • Timing of Adjuvant Radiation Therapy and Risk of Wound-Related Complications Among Patients With Spinal Metastatic Disease GLOBAL SPINE JOURNAL Azad, T. D., Varshneya, K., Herrick, D. B., Pendharkar, A., Ho, A. L., Stienen, M., Zygourakis, C., Bagshaw, H. P., Veeravagu, A., Ratliff, J. K., Desai, A. 2019
  • Outcomes After Cervical Disc Arthroplasty Versus Stand-Alone Anterior Cervical Discectomy and Fusion: A Meta-Analysis GLOBAL SPINE JOURNAL Gendreau, J. L., Kim, L. H., Prins, P. N., D'Souza, M., Rezaii, P., Pendharkar, A., Sussman, E. S., Ho, A. L., Desai, A. M. 2019
  • Outcomes After Cervical Disc Arthroplasty Versus Stand-Alone Anterior Cervical Discectomy and Fusion: A Meta-Analysis. Global spine journal Gendreau, J. L., Kim, L. H., Prins, P. N., D'Souza, M., Rezaii, P., Pendharkar, A. V., Sussman, E. S., Ho, A. L., Desai, A. M. 2019: 2192568219888448

    Abstract

    Systemic review and meta-analysis.To review and compare surgical outcomes for patients undergoing stand-alone anterior cervical discectomy and fusion (ACDF) versus cervical disc arthroplasty (CDA) for the treatment of cervical spine disease.A systematic search was performed on PubMed, Medline, and the Cochrane Library. Comparative trials measuring outcomes of patients undergoing CDA and stand-alone ACDF for degenerative spine disease in the last 10 years were selected for inclusion. After data extraction and quality assessment, statistical analysis was performed with R software metafor package. The random-effects model was used if there was heterogeneity between studies; otherwise, the fixed-effects model was used.In total, 12 studies including 859 patients were selected for inclusion in the meta-analysis. Patients undergoing stand-alone ACDF had a statistically significant increase in postoperative segmental angles (mean difference 0.85° [95% confidence interval = 0.35° to 1.35°], P = .0008). Patients undergoing CDA had a decreased rate of developing adjacent segmental degeneration (risk ratio = 0.56 [95% confidence interval = -0.06 to 1.18], P = .0745). Neck Disability Index, Japanese Orthopedic Association score, Visual Analogue Scale of the arm and neck, as well as postoperative cervical angles were similar between the 2 treatments.When compared with CDA, stand-alone ACDF offers similar clinical outcomes for patients and leads to increased postoperative segmental angles. We encourage further blinded randomized trials to compare rates of adjacent segmental degeneration and other postoperative outcomes between these 2 treatments options.

    View details for DOI 10.1177/2192568219888448

    View details for PubMedID 32875831

  • Propensity-matched Comparison of Outcomes and Costs After Macroscopic and Microscopic Anterior Cervical Corpectomy Using a National Longitudinal Database. Spine Ho, A. L., Rezaii, P. G., Pendharkar, A. V., Sussman, E. S., Veeravagu, A., Ratliff, J. K., Desai, A. M. 2019; 44 (21): E1281–E1288

    Abstract

    STUDY DESIGN: A retrospective analysis of national longitudinal database.OBJECTIVE: The aim of this study was to examine the outcomes and cost-effectiveness of operating microscope utilization in anterior cervical corpectomy (ACC).SUMMARY OF BACKGROUND DATA: The operating microscope allows for superior visualization and facilitates ACC with less manipulation of tissue and improved decompression of neural elements. However, many groups report no difference in outcomes with increased cost associated with microscope utilization.METHODS: A longitudinal database (MarketScan) was utilized to identify patients undergoing ACC with or without microscope between 2007 and 2016. Propensity matching was performed to normalize differences between the two cohorts. Outcomes and costs were subsequently compared.RESULTS: A total of 11,590 patients were identified for the "macroscopic" group, while 4299 patients were identified for the "microscopic" group. For the propensity-matched analysis, 4298 patients in either cohort were successfully matched according to preoperative characteristics. Hospital length of stay was found to be significantly longer in the macroscopic group than the microscopic group (1.86 nights vs. 1.56 nights, P < 0.0001). Macroscopic ACC patients had an overall higher rate of readmissions [30-day: 4.2% vs. 3.2%, odds ratio (OR) = 0.76 (0.61-0.96), P = 0.0223; 90-day: 7.0% vs. 5.9%, OR = 0.82 (0.69-0.98), P = 0.0223]. Microscopic ACC patients had a higher rate of discharge to home [86.6% vs. 92.5%, OR = 1.91 (1.65-2.21), P < 0.0001] and lower rates of new referrals to pain management [1.0% vs. 0.4%, OR = 0.42 (0.23-0.74), P = 0.0018] compared with macroscopic ACC. Postoperative complication rate was not found to be significantly different between the groups. Finally, total initial admission charges were not significantly different between the macroscopic and microscopic groups (

  • Conventional Versus Stereotactic Image-guided Pedicle Screw Placement During Posterior Lumbar Fusions: A Retrospective Propensity Score-matched Study of a National Longitudinal Database. Spine Pendharkar, A. V., Rezaii, P. G., Ho, A. L., Sussman, E. S., Veeravagu, A., Ratliff, J. K., Desai, A. M. 2019; 44 (21): E1272–E1280

    Abstract

    STUDY DESIGN: Retrospective 1:1 propensity score-matched analysis on a national longitudinal database between 2007 and 2016.OBJECTIVE: The aim of this study was to compare complication rates, revision rates, and payment differences between navigated and conventional posterior lumbar fusion (PLF) procedures with instrumentation.SUMMARY OF BACKGROUND DATA: Stereotactic navigation techniques for spinal instrumentation have been widely demonstrated to improve screw placement accuracies and decrease perforation rates when compared to conventional fluoroscopic and free-hand techniques. However, the clinical utility of navigation for instrumented PLF remains controversial.METHODS: Patients who underwent elective laminectomy and instrumented PLF were stratified into "single level" and "3- to 6-level" cohorts. Navigation and conventional groups within each cohort were balanced using 1:1 propensity score matching, resulting in 1786 navigated and conventional patients in the single-level cohort and 2060 in the 3 to 6 level cohort. Outcomes were compared using bivariate analysis.RESULTS: For the single-level cohort, there were no significant differences in rates of complications, readmissions, revisions, and length of stay between the navigation and conventional groups. For the 3- to 6-level cohort, length of stay was significantly longer in the navigation group (P < 0.0001). Rates of readmissions were, however, greater for the conventional group (30-day: P = 0.0239; 90-day: P = 0.0449). Overall complications were also greater for the conventional group (P = 0.0338), whereas revision rate was not significantly different between the 2 groups. Total payments were significantly greater for the navigation group in both the single level and 3- to 6-level cohorts (P < 0.0001).CONCLUSION: Although use of navigation for 3- to 6-level instrumented PLF was associated with increased length of stay and payments, the concurrent decreased overall complication and readmission rates alluded to its potential clinical utility. However, for single-level instrumented PLF, no differences in outcomes were found between groups, suggesting that the value in navigation may lie in more complex procedures.LEVEL OF EVIDENCE: 3.

    View details for DOI 10.1097/BRS.0000000000003130

    View details for PubMedID 31634303

  • Trends in Anterior Lumbar Interbody Fusion in the United States: A MarketScan Study From 2007 to 2014. Clinical spine surgery Varshneya, K., Medress, Z. A., Jensen, M., Azad, T. D., Rodrigues, A., Stienen, M. N., Desai, A., Ratliff, J. K., Veeravagu, A. 2019

    Abstract

    BACKGROUND: Although the incidence of spinal fusions has increased significantly in the United States over the last quarter century, national trends of anterior lumbar interbody fusion (ALIF) utilization are not known.PURPOSE: The objective of this study was to characterize trends, clinical characteristics, risk factors associated with, and outcomes of ALIF in the United States.STUDY DESIGN: This was an epidemiological study using national administrative data from the MarketScan database.METHODS: Using a large administrative database, we identified adults who underwent ALIF in the United States from 2007 to 2014. The incidence of ALIF was studied longitudinally over time and across geographic regions in the United States. Data related to postoperative complications, length of stay, readmission, and cost were collected.RESULTS: We identified 49,945 patients that underwent ALIF in the United States between 2007 and 2014. The total number of ALIF procedures increased from 3650 in 2007 to 6151 in 2014, accounting for an average increase of 24.07% annually. The Southern United States performed the highest number of ALIFs. The most common conditions treated were degenerative disc disease and spondylolisthesis. Over one third of patients (34.6%) underwent multilevel fusion. The most common complications were iron deficiency anemia, urinary tract infections, and pulmonary complications. Hospital and physician pay increased significantly during the study period.CONCLUSIONS: For the first time in our knowledge, we identified national trends in ALIF utilization, outcomes, and cost using a large administrative database. Our study reaffirms prior work that has demonstrated low rates of complications, mortality, and readmission following ALIF.LEVEL OF EVIDENCE: Level III.

    View details for DOI 10.1097/BSD.0000000000000904

    View details for PubMedID 31609798

  • Objective measures of functional impairment for degenerative diseases of the lumbar spine: a systematic review of the literature SPINE JOURNAL Stienen, M. N., Ho, A. L., Staartjes, V. E., Maldaner, N., Veeravagu, A., Desai, A., Gautschi, O. P., Bellut, D., Regli, L., Ratliff, J. K., Park, J. 2019; 19 (7): 1276–93
  • Patient Satisfaction and Press Ganey Scores for Spine Versus Nonspine Neurosurgery Clinics. Clinical spine surgery Chen, Y., Johnson, E., Montalvo, C., Stratford, S., Veeravagu, A., Tharin, S., Desai, A., Ratliff, J., Shuer, L., Park, J. 2019

    Abstract

    STUDY DESIGN: Retrospective survey review.OBJECTIVE: We seek to evaluate satisfaction scores in patients seen in neurosurgical spine versus neurosurgical nonspine clinics.SUMMARY OF BACKGROUND DATA: The Press Ganey survey is a well-established metric for measuring hospital performance and patient satisfaction. These measures have important implications in setting hospital policy and guiding interventions to improve patient perceptions of care.METHODS: Retrospective Press Ganey survey review was performed to identify patient demographics and patient visit characteristics from January 1st, 2012 to October 10th, 2017 at Stanford Medical Center. A total of 40 questions from the Press Ganey survey were investigated and grouped in categories addressing physician and nursing care, personal concerns, admission, room, meal, operating room, treatment and discharge conditions, visitor accommodations and overall clinic assessment. Raw ordinal scores were converted to continuous scores of 100 for unpaired student t test analysis. We identified 578 neurosurgical spine clinic patients and 1048 neurosurgical nonspine clinic patients.RESULTS: Spine clinic patients reported lower satisfaction scores in aggregate (88.2 vs. 90.1; P=0.0014), physician (89.5 vs. 92.6; P=0.0002) and nurse care (91.3 vs. 93.4; P=0.0038), personal concerns (88.2 vs. 90.9; P=0.0009), room (81.0 vs. 83.1; P=0.0164), admission (90.8 vs. 92.6; P=0.0154) and visitor conditions (87.0 vs. 89.2; P=0.0148), and overall clinic assessment (92.9 vs. 95.5; P=0.005).CONCLUSIONS: This study is the first to evaluate the relationship between neurosurgical spine versus nonspine clinic with regards to patient satisfaction. The spine clinic cohort reported less satisfaction than the nonspine cohort in all significant questions on the Press Ganey survey. Our findings suggest that efforts should be made to further study and improve patient satisfaction in spine clinics.LEVEL OF EVIDENCE: Level III.

    View details for DOI 10.1097/BSD.0000000000000825

    View details for PubMedID 30969193

  • Socioeconomic Predictors of Surgical Resection and Survival for Patients With Osseous Spinal Neoplasms CLINICAL SPINE SURGERY Deb, S., Brewster, R., Pendharkar, A., Veeravagu, A., Ratliff, J., Desai, A. 2019; 32 (3): 125–31
  • Socioeconomic Predictors of Pituitary Surgery. Cureus Deb, S., Vyas, D. B., Pendharkar, A. V., Rezaii, P. G., Schoen, M. K., Desai, K., Gephart, M. H., Desai, A. 2019; 11 (1): e3957

    Abstract

    There exists a lack of data on the effect of socioeconomic status (SES) on outcomes for pituitary tumors, which have been associated with significant morbidity. The goal of this population-level study is to investigate the role of SES on receiving treatment and survival in patients with pituitary tumors.The Surveillance, Epidemiology, and End Results (SEER) program database from the National Cancer Institute was used to identify patients diagnosed with pituitary tumors between 2003 and 2012. SES was determined using a validated composite index. Race was categorized as Caucasian and non-Caucasian. Treatment received included surgery, radiation, and radiation with surgery. Odds of receiving surgery and survival probability were analyzed using multivariate logistic regression and Cox proportional hazards model, respectively.A total of 25,802 patients with pituitary tumors were identified for analysis. High SES tertile (odds ratio (OR) = 1.095; 95% confidence interval (CI) [1.059, 1.132]) and quintile (OR = 1.052; 95% CI [1.031, 1.072]) were associated with higher odds of receiving surgery (p<0.0001). Caucasian patients had higher odds of receiving surgery when compared to non-Caucasian patients (OR = 1.064; 95% CI [1.000, 1.133]; p<0.05). Neither SES nor race were significant predictors of survival probability.Socioeconomic status and race were found to be associated with higher odds of receiving surgery for pituitary tumors, and thus serve as independent predictors of surgical management. Further studies are required to investigate possible causes for these findings.

    View details for DOI 10.7759/cureus.3957

    View details for PubMedID 30956910

    View details for PubMedCentralID PMC6436671

  • Outcomes and costs following Ommaya placement with thrombocytopenia among US cancer patients. World neurosurgery Zhang, M. n., Zhang, Y. n., Zheng, E. n., Gephart, M. H., Veeravagu, A. n., Desai, A. n., Ratliff, J. K., Li, G. n. 2019

    Abstract

    Placement of Ommaya reservoirs for administration of intrathecal chemotherapy may be complicated by comorbid thrombocytopenia among patients with hematologic or leptomeningeal disease. Aggregated data on risks of Ommaya placement among thrombocytopenic patients is lacking. This study assesses complications, revision rates, and costs associated with Ommaya placement among patients with thrombocytopenia in a large population sample.Using a national administrative database, this retrospective study identifies a cohort of adult cancer patients who underwent Ommaya placement between 2007 and 2016. Preoperative thrombocytopenia was defined as diagnosis of secondary thrombocytopenia, bleeding event, procedure to control bleeding, or platelet transfusion, within 30 days prior to index admission. Univariate and multivariate analyses were performed to assess costs, 30-day complications, readmissions, and revisions among patients with and without preoperative thrombocytopenia.The analytic cohort included 1652 patients, of whom 29.3% met criteria for preoperative thrombocytopenia. In-hospital mortality rates were 7.7% among thrombocytopenic patients vs. 1.2% among non-thrombocytopenic patients (p < 0.001). Preoperative thrombocytopenia was associated with 14.5 times greater hazard of intracranial hemorrhage within 30 days following Ommaya placement, occurring in 25.6% vs. 2.0% of thrombocytopenic and non-thrombocytopenic patients, respectively (p < 0.014). Revision rates did not differ significantly between thrombocytopenic and non-thrombocytopenic patients. Thrombocytopenia was associated with longer length of stay (7.4 vs 13.9 days, p < 0.001) and additional

  • Reliability of the 6-minute walking test smartphone application. Journal of neurosurgery. Spine Stienen, M. N., Gautschi, O. P., Staartjes, V. E., Maldaner, N. n., Sosnova, M. n., Ho, A. L., Veeravagu, A. n., Desai, A. n., Zygourakis, C. C., Park, J. n., Regli, L. n., Ratliff, J. K. 2019: 1–8

    Abstract

    Objective functional measures such as the 6-minute walking test (6WT) are increasingly applied to evaluate patients with degenerative diseases of the lumbar spine before and after (surgical) treatment. However, the traditional 6WT is cumbersome to apply, as it requires specialized in-hospital infrastructure and personnel. The authors set out to compare 6-minute walking distance (6WD) measurements obtained with a newly developed smartphone application (app) and those obtained with the gold-standard distance wheel (DW).The authors developed a free iOS- and Android-based smartphone app that allows patients to measure the 6WD in their home environment using global positioning system (GPS) coordinates. In a laboratory setting, the authors obtained 6WD measurements over a range of smartphone models, testing environments, and walking patterns and speeds. The main outcome was the relative measurement error (rME; in percent of 6WD), with

  • Analysis of Outcomes and Cost of Inpatient and Ambulatory Anterior Cervical Disk Replacement Using a State-level Database. Clinical spine surgery Purger, D. A., Pendharkar, A. V., Ho, A. L., Sussman, E. S., Veeravagu, A. n., Ratliff, J. K., Desai, A. M. 2019

    Abstract

    Outpatient cervical artificial disk replacement (ADR) is a promising candidate for cost reduction. Several studies have demonstrated low overall complications and minimal readmission in anterior cervical procedures.The objective of this study was to compare clinical outcomes and cost associated between inpatient and ambulatory setting ADR.Outcomes and cost were retrospectively analyzed for patients undergoing elective ADR in California, Florida, and New York from 2009 to 2011 in State Inpatient and Ambulatory Databases.A total of 1789 index ADR procedures were identified in the inpatient database (State Inpatient Databases) compared with 370 procedures in the ambulatory cohort (State Ambulatory Surgery and Services Databases). Ambulatory patients presented to the emergency department 19 times (5.14%) within 30 days of the index procedure compared with 4.2% of inpatients. Four unique patients underwent readmission within 30 days in the ambulatory ADR cohort (1% total) compared with 2.2% in the inpatient ADR group. No ambulatory ADR patients underwent a reoperation within 30 days. Of the inpatient ADR group, 6 unique patients underwent reoperation within 30 days (0.34%, Charlson Comorbidity Index zero=0.28%, Charlson Comorbidity Index>0=0.6%). There was no significant difference in emergency department visit rate, inpatient readmission rate, or reoperation rates within 30 days of the index procedure between outpatient or inpatient ADR. Outpatient ADR is noninferior to inpatient ADR in all clinical outcomes. The direct cost was significantly lower in the outpatient ADR group (

  • Clinical efficacy of frameless stereotactic radiosurgery in the management of spinal metastases from thyroid carcinoma. Spine Hariri, O. n., Takayanagi, A. n., Lischalk, J. n., Desai, K. n., Florence, T. J., Yazdian, P. n., Chang, S. D., Vrionis, F. n., Adler, J. R., Quadri, S. A., Desai, A. n. 2019

    Abstract

    MINI: Study evaluates the efficacy of CyberKnife® (CK) SRS for thyroid spinal metastases (SM). Patients with SMs from thyroid carcinoma that were treated with CK SRS between 2003 and 2013were identified. CK can be safely used to treat SMs from thyroid cancer with a high rate of local control.A retrospective data review.To evaluate the efficacy of CyberKnife® SRS for thyroid SMs.Thyroid carcinoma is an infrequent cause of spinal metastasis (SM). The absolute efficacy of stereotactic radiosurgery (SRS) generally and CyberKnife® (CK) in particular remains poorly characterized for thyroid SM. The current study is the first to specifically evaluate the efficacy of CyberKnife® SRS for thyroid SMs.A retrospective review of patients at our institution between 2003 and 2013 was done. Details about tumor location, radiographic findings before and after CK SRS, tumor recurrence, prescription isodose level, total and maximum dose, number of fractions, and gross tumor volume coverage were similarly collected. For comparison with other studies, the biologically effective dose (BED) and the equivalent total dose in 2Gy fractions (EQD2) were calculated. Each patient was assessed for survival and local disease control from the time of the first CK session and survival analysis was carried out using the Kaplan-Meier method. Risk factors for local failure were assessed using multivariate logistic regression.A total of 12 patients with 32 spinal metastases from thyroid carcinoma that were treated with CK SRS were identified. Survival for 1, 2, and 3 years was 55%, 44%, and 33%, and local control was 67%, 56%, and 34% respectively. The study found that the single strongest factor associated with local control was prior radiotherapy (β-coefficient -27.72, p = 0.01). No complications occurred in the immediate or late follow-up period.This was the first study to specifically investigate the efficacy of CK for treatment of thyroid SMs. Our findings suggest that CK can be safely used to treat spinal SMs from thyroid cancer and is associated with a high rate of local control.4.

    View details for DOI 10.1097/BRS.0000000000003087

    View details for PubMedID 31261273

  • Trans-Oral Endoscopic Resection of High Cervical Osteophytes with Long-term Symptom Resolution: Case Series, Imaging, and Literature Review. World neurosurgery Jabarkheel, R., Chen, Y., Xu, L., Yan, C. H., Patel, Z. M., Desai, A. M. 2018

    Abstract

    BACKGROUND: Anterior cervical osteophytes (ACOs) are a common radiological finding in the elderly; rarely, they can cause dysphagia, dysphonia, and dyspnea. Symptomatic ACOs are most commonly found between C4-C7 and much less commonly at higher cervical levels. Here, we present a case series, with an example case of a 57-year-old woman with high cervical osteophytes at C1-C2 causing globus sensation, dysphagia, and dysphonia. Additionally, we provide a literature review regarding the etiology, diagnosis, and treatment of ACOs with a focus on management of high ACOs.CASE DESCRIPTION: A 57 year-old smoker with a history of chronic neck pain and previous cervical spinal instrumentation presented with several months of globus sensation, dysphagia, and dysphonia. Imaging revealed two large anterior osteophytes at C1-C2. She underwent endoscopic trans-oral osteophytectomy with resolution of symptoms. Five other patients are also presented who underwent similar procedures.CONCLUSIONS: ACOs are a potential cause of dysphagia, and their diagnosis is best made with CT imaging and oropharyngeal swallow study. Although high ACOs at C1-C2 are a rare finding, here we show with an exemplary case and small case series that they can be effectively treated with trans-oral endoscopic osteophytectomy.

    View details for PubMedID 30193964

  • Anterior Techniques in Managing Cervical Disc Disease. Cureus Kim, L. H., D'Souza, M., Ho, A. L., Pendharkar, A. V., Sussman, E. S., Rezaii, P., Desai, A. 2018; 10 (8): e3146

    Abstract

    Surgical treatment may be indicated for select patients with cervical disc disease, whether it is cervical disc herniation or spondylosis due to degenerative changes, acute cervical injury due to trauma, or other underlying cervical pathology.Currently, there are various surgical techniques, including anterior, posterior, or combined approaches, in addition to new interventions being utilized in practice. Ideally, the surgical approach should be selected in consideration of each patient's clinical presentation, imaging findings, and overall medical comorbidities on an individual basis. But the unique advantages and disadvantages of each surgical technique often complicate the therapy choice in managing cervical disc diseases. Although anterior cervical discectomy and fusion (ACDF) is the most widely accepted procedure performed for both single and multi-level cervical disc diseases, there are multiple modifications to this technique. Surgeons have access to different types of plates, screws, and cages and can adopt newer advances in the field such as stand-alone and minimally invasive techniques when indicated. In short, no consensus exists in terms of a single approach that is preferredfor all patients. This article aims to review the standard of care for management of cervical disc disease with a focus on the surgical techniques and, in particular, the anterior approach, exploring the various surgical options within this technique.

    View details for PubMedID 30410821

  • Outpatient spine surgery: defining the outcomes, value, and barriers to implementation. Neurosurgical focus Pendharkar, A. V., Shahin, M. N., Ho, A. L., Sussman, E. S., Purger, D. A., Veeravagu, A., Ratliff, J. K., Desai, A. M. 2018; 44 (5): E11

    Abstract

    Spine surgery is a key target for cost reduction within the United States health care system. One possible strategy involves the transition of inpatient surgeries to the ambulatory setting. Lumbar laminectomy with or without discectomy, lumbar fusion, anterior cervical discectomy and fusion, and cervical disc arthroplasty all represent promising candidates for outpatient surgeries in select populations. In this focused review, the authors clarify the different definitions used in studies describing outpatient spine surgery. They also discuss the body of evidence supporting each of these procedures and summarize the proposed cost savings. Finally, they examine several patient- and surgeon-specific considerations to highlight the barriers in translating outpatient spine surgery into actual practice.

    View details for PubMedID 29712520

  • Propensity-matched comparison of outcomes and cost after macroscopic and microscopic lumbar discectomy using a national longitudinal database. Neurosurgical focus Pendharkar, A. V., Rezaii, P. G., Ho, A. L., Sussman, E. S., Purger, D. A., Veeravagu, A., Ratliff, J. K., Desai, A. M. 2018; 44 (5): E12

    Abstract

    OBJECTIVE There has been considerable debate about the utility of the operating microscope in lumbar discectomy and its effect on outcomes and cost. METHODS A commercially available longitudinal database was used to identify patients undergoing discectomy with or without use of a microscope between 2007 and 2015. Propensity matching was performed to normalize differences between demographics and comorbidities in the 2 cohorts. Outcomes, complications, and cost were subsequently analyzed using bivariate analysis. RESULTS A total of 42,025 patients were identified for the "macroscopic" group, while 11,172 patients were identified for the "microscopic" group. For the propensity-matched analysis, the 11,172 patients in the microscopic discectomy group were compared with a group of 22,340 matched patients who underwent macroscopic discectomy. There were no significant differences in postoperative complications between the groups other than a higher proportion of deep vein thrombosis (DVT) in the macroscopic discectomy cohort versus the microscopic discectomy group (0.4% vs 0.2%, matched OR 0.48 [95% CI 0.26-0.82], p = 0.0045). Length of stay was significantly longer in the macroscopic group compared to the microscopic group (mean 2.13 vs 1.83 days, p < 0.0001). Macroscopic discectomy patients had a higher rate of revision surgery when compared to microscopic discectomy patients (OR 0.92 [95% CI 0.84-1.00], p = 0.0366). Hospital charges were higher in the macroscopic discectomy group (mean

  • Efficacy and safety of corpus callosotomy after vagal nerve stimulation in patients with drug-resistant epilepsy JOURNAL OF NEUROSURGERY Hong, J., Desai, A., Thadani, V. M., Roberts, D. W. 2018; 128 (1): 277–86

    Abstract

    OBJECTIVE Vagal nerve stimulation (VNS) and corpus callosotomy (CC) have both been shown to be of benefit in the treatment of medically refractory epilepsy. Recent case series have reviewed the efficacy of VNS in patients who have undergone CC, with encouraging results. There are few data, however, on the use of CC following VNS therapy. METHODS The records of all patients at the authors' center who underwent CC following VNS between 1998 and 2015 were reviewed. Patient baseline characteristics, operative details, and postoperative outcomes were analyzed. RESULTS Ten patients met inclusion criteria. The median follow-up was 72 months, with a minimum follow-up of 12 months (range 12-109 months). The mean time between VNS and CC was 53.7 months. The most common reason for CC was progression of seizures after VNS. Seven patients had anterior CC, and 3 patients returned to the operating room for a completion of the procedure. All patients had a decrease in the rate of falls and drop seizures; 7 patients experienced elimination of drop seizures. Nine patients had an Engel Class III outcome, and 1 patient had a Class IV outcome. There were 3 immediate postoperative complications and 1 delayed complication. One patient developed pneumonia, 1 developed transient mutism, and 1 had persistent weakness in the nondominant foot. One patient presented with a wound infection. CONCLUSIONS The authors demonstrate that CC can help reduce seizures in patients with medically refractory epilepsy following VNS, particularly with respect to drop attacks.

    View details for PubMedID 28298036

  • Preoperative depression, lumbar fusion, and opioid use: an assessment of postoperative prescription, quality, and economic outcomes. Neurosurgical focus O'Connell, C. n., Azad, T. D., Mittal, V. n., Vail, D. n., Johnson, E. n., Desai, A. n., Sun, E. n., Ratliff, J. K., Veeravagu, A. n. 2018; 44 (1): E5

    Abstract

    OBJECTIVE Preoperative depression has been linked to a variety of adverse outcomes following lumbar fusion, including increased pain, disability, and 30-day readmission rates. The goal of the present study was to determine whether preoperative depression is associated with increased narcotic use following lumbar fusion. Moreover, the authors examined the association between preoperative depression and a variety of secondary quality indicator and economic outcomes, including complications, 30-day readmissions, revision surgeries, likelihood of discharge home, and 1- and 2-year costs. METHODS A retrospective analysis was conducted using a national longitudinal administrative database (MarketScan) containing diagnostic and reimbursement data on patients with a variety of private insurance providers and Medicare for the period from 2007 to 2014. Multivariable logistic and negative binomial regressions were performed to assess the relationship between preoperative depression and the primary postoperative opioid use outcomes while controlling for demographic, comorbidity, and preoperative prescription drug-use variables. Logistic and log-linear regressions were also used to evaluate the association between depression and the secondary outcomes of complications, 30-day readmissions, revisions, likelihood of discharge home, and 1- and 2-year costs. RESULTS The authors identified 60,597 patients who had undergone lumbar fusion and met the study inclusion criteria, 4985 of whom also had a preoperative diagnosis of depression and 21,905 of whom had a diagnosis of spondylolisthesis at the time of surgery. A preoperative depression diagnosis was associated with increased cumulative opioid use (β = 0.25, p < 0.001), an increased risk of chronic use (OR 1.28, 95% CI 1.17-1.40), and a decreased probability of opioid cessation (OR 0.96, 95% CI 0.95-0.98) following lumbar fusion. In terms of secondary outcomes, preoperative depression was also associated with a slightly increased risk of complications (OR 1.14, 95% CI 1.03-1.25), revision fusions (OR 1.15, 95% CI 1.05-1.26), and 30-day readmissions (OR 1.19, 95% CI 1.04-1.36), although it was not significantly associated with the probability of discharge to home (OR 0.92, 95% CI 0.84-1.01). Preoperative depression also resulted in increased costs at 1 (β = 0.06, p < 0.001) and 2 (β = 0.09, p < 0.001) years postoperatively. CONCLUSIONS Although these findings must be interpreted in the context of the limitations inherent to retrospective studies utilizing administrative data, they provide additional evidence for the link between a preoperative diagnosis of depression and adverse outcomes, particularly increased opioid use, following lumbar fusion.

    View details for DOI 10.3171/2017.10.FOCUS17563

    View details for PubMedID 29290135